Information for patients regarding gastroscopy with insertion of a percutaneous endoscopic gastrostomy tube (PEG) Information briefing given by: Date: Dear Patient, Label Please read these documents as soon as you receive them. Complete the questionnaire, and sign and date the documents on the day before the investigation if possible. If you have any questions, contact your doctor or specialist physician (gastroenterologist). You are to have a gastroscopy with insertion of a percutaneous endoscopic gastrostomy tube (PEG). For this investigation you will receive: an information sheet a questionnaire a declaration of consent The information sheet: The information sheet contains information about the study procedure, its objectives and risks. Please read this sheet carefully. If you have further questions on the necessity for and urgency of the investigation, alternatives to or risks of the investigation, contact your doctor. The doctor who registered you for the investigation will be able to answer the majority of these questions. Specific questions on the technical procedure of the investigation or specific problems can be answered if necessary by the specialist physician (gastroenterologist) conducting the procedure. If you would like answers from the doctor or gastroenterologist, please approach us or the referring doctor as soon as possible. The questionnaire: Please make sure you complete the attached questionnaire in full, so we can determine your tendency to bleed, and answer the questions relating to medication, intolerances or allergies. If you are on anticoagulant medication to thin the blood (e.g. Sintrom, Marcoumar, Xarelto) or are regularly taking Aspirin, Alcacyl, Tiatral, Plavix, Clopidogrel etc., please discuss possibly discontinuing your medication with your doctor in good time (at least 1 week before the investigation). Please bring the questionnaire to the investigation with you. Please sign and date the questionnaire, if possible one day prior to the investigation. If you have any problems or queries when answering the questions, please contact your doctor or us in good time. The declaration of consent:
Please also read the declaration of consent carefully. Also sign and date it on the day before the investigation at the latest. You are supposed to keep the information sheet. The questionnaire and informed consent will be stored here in the medical records. Information sheet about gastroscopy with insertion of a percutaneous endoscopic gastrostomy tube (PEG) Why is a gastroscopy with insertion of a PEG percutaneous endoscopic gastrostomy tube being performed? During gastroscopy the oesophagus, stomach and duodenum are examined. This procedure will detect disorders in these organs (e.g. inflammation, ulcers, varicose veins, polyps or tumours) and treat some disorders, or check the progress of known disorders. To ensure that you receive adequate nutrition, you are to have a PEG (= thin tube) inserted in your stomach or small intestine through the wall of your abdomen. The gastrostomy tube can be left in place for a long time but if it is no longer required it can also be easily removed. Despite the tube, you may eat and drink normally if your physician agrees. What preparations are necessary for gastroscopy with insertion of a percutaneous endoscopic gastrostomy tube (PEG)? Please do not eat any solid food from midnight on the night before the gastroscopy because the upper digestive tract must be free of food residues for the gastroscopy. You are permitted to drink clear, fat-free liquids (not milk) up to 2 hours before the start of the investigation. Do not take your regular medication unless your doctor has expressly requested you to do so. You will usually be given an antibiotic as prophylaxis before insertion of the percutaneous endoscopic gastrostomy tube (PEG). Ability to drive/work? You will usually be given sleeping pills and/or analgesics for the investigation. Driving is not advised after taking these medications. Do not come in your own car. Make sure you have someone to accompany you. After taking these medications you should not sign anything for 12 hours. This means that you should not sign any contracts during this time. What is the procedure for gastroscopy? First a drip will be placed in your arm for possible administration of sleeping and sedative medication. The investigation will be performed using a flexible thin tube, at the tip of which is a light source and a camera. The doctor is able to examine the mucous membrane of the organs mentioned in this way, and look for pathological changes. Apart from an accurate inspection of the mucous membrane, tissue samples can be removed or various interventions undertaken, such as haemostasis (stoppage of bleeding) or removal of tissues. The investigation and additional interventions are not painful. During the investigation, a speciallytrained nurse practitioner (nurse or practice assistant) is also present in addition to the doctor. There are two methods for inserting the PEG tube. It is not always possible to state in advance which method will be used. During the investigation, your doctor will choose the method which is most suitable for you. 1. Inserting the tube through the mouth ( Pull-through method ) During gastroscopy, while you are asleep, the upper abdomen will be locally anaesthetised and a needle passed into the stomach at this point. A guide wire will be introduced through this needle, collected by the endoscope in the stomach and passed out through the mouth. The PEG tube will then be connected to this guide wire and pulled into the stomach through the mouth. The PEG tube will be attached by a small button to the outside of the abdominal wall.
2. Insertion through the abdominal wall under endoscopic surveillance ( Push-PEG method ) The upper abdomen is locally anaesthetised. Then the stomach wall is attached to the abdominal wall using two thin guidewires under endoscopic surveillance and the stomach is punctured with a cannula under endoscopic guidance. The needle is removed and a PEG tube with balloon is introduced into the stomach from outside. The balloon at the end of the PEG tube is inflated with water and prevents the tube escaping from the stomach. The guide wires are pulled out after 1-4 weeks. The tube must be exchanged after 3-4 weeks but endoscopy does not need to be performed again. What risks are associated with gastroscopy? Complications of gastroscopy are extremely rare (0.2 ). However, despite thorough care, complications can occur, which may also be life-threatening in exceptional circumstances. The following should be mentioned: allergic reactions, possible tooth damage if teeth are already decayed, infection, bleeding, injury to the wall of the upper digestive tract (perforation) and injury to the larynx. In rare cases administration of sleeping medication may cause impairment of respiratory and cardiac function. Gastroscopy may cause mild hoarseness, swallowing difficulties or unpleasant flatulence (due to residual air in the stomach and small intestine) for a short time after the procedure. After insertion of a PEG tube 20% of patients experience pain, redness around the puncture site, and local infections of the abdominal wall. Very rarely (<1%) bleeding may develop, or even more rarely (<1 ) an organ in the abdominal cavity may be damaged (liver, large or small intestine). These complications may result in surgery. What should I do after the investigation? After the investigation you should not eat or drink for 6 hours. After this you are permitted to drink clear fluids. Your doctor will identify the time you can start ingesting food again through your mouth or receiving enteral nutrition via the PEG. If you should develop abdominal pain or other disorders (e.g. dizziness, nausea, vomiting), or blood is discharged from the anus (usually in the form of black, watery stool) following the gastroscopy, you must inform your doctor immediately or go to A+E. You will be given an individually-tailored nutrition plan by the doctor or nutritional adviser. Persons concerned (nursing staff, home care personnel) will be instructed in the handling and care of the tube. Questions about the investigation?
If you have any further questions on the planned investigation please contact your G.P. If you still have queries after that, contact the specialist physician (gastroenterologist) who is to perform the investigation on you. If you have questions or problems you can get in touch with the following doctors: G.P. Gastroenterologist Tel: Tel:
Questionnaire Questions relating to bleeding tendency: yes no 1. Do you get severe nosebleeds without any apparent reason? 2. Do you get bleeding gums without any apparent reason (when you clean your teeth)? 3. Do you get bruises (haematoma) or small bleeds on the skin without any apparent injuries? 4. Do you feel that you bleed for longer after small injuries (e.g. when shaving)? 5. For women: Do you feel that your periods are prolonged (lasting longer than 7 days) or that you have to change your tampons or sanitary towels very frequently? 6. Do you experience prolonged or severe bleeding during or after a dental treatment? 7. Do you experience prolonged or severe bleeding during or after surgery (e.g. tonsillectomy, appendectomy, childbirth)? 8. Have you been given banked blood or blood products during surgery? 9. Do you have a family history (parents, siblings, children, grandparents, uncles, aunts) of illnesses that increase the tendency to bleed? Questions about medication, allergies, accompanying illnesses: 1. Are you taking anticoagulant medication to thin your blood (e.g. Sintrom, Marcoumar, Xarelto) or have you taken Aspirin, Alcacyl, Tiatral, Plavix, Clopidogrel etc., or cold remedies, analgesics or antirheumatics in the last 7 days? If yes, which? 2. Do you have an allergy/hypersensitivity reaction (to medications, latex, local anaesthetics, sticking plasters)? If yes, which? 3. Do you have a heart valve defect, heart disease or lung disease? Do you carry an endocarditis prophylaxis warning card (green/red)? 4. Do you wear a heart pacemaker/defibrillator or metal implant? 5. Are you known to have a kidney function disorder (renal failure)? 6. Are you a diabetic? 7. For women: Are you pregnant or is there a possibility that you may be pregnant? I, the undersigned, have completed the questionnaire to the best of my knowledge. Place, date Name of patient Signature of patient
Informed consent for gastroscopy with insertion of a PEG percutaneous endoscopic gastrostomy tube Label Information briefing given by: Date: I, the undersigned, have read the information sheet carefully. The doctor has explained to me the reason (indication) for the gastroscopy with insertion of a PEG percutaneous endoscopic gastrostomy tube. I have understood the nature, procedures and risks of the gastroscopy with insertion of a PEG percutaneous endoscopic gastrostomy tube. My questions have been answered to my satisfaction. I consent to the gastroscopy with insertion of a PEG percutaneous endoscopic gastrostomy tube I consent to the administration of sleeping medication and/or analgesic medication for the investigation (Make a cross in the appropriate box) Yes No Yes No Name of patient Name of doctor Place, date Signature of patient Place, date Signature of doctor For patients who are unable to sign their own consent: Legal representative or duly authorised person Name of doctor Place, date Signature of representative Place, date Signature of doctor